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27_Abd pain-1435.ppt
1. Approach To Abdominal Pain
Dr. Nahla A Azzam MRCP,FACP
Assistant Professor &Consultant
Gastroenterology
2. • One of the most common causes for OP & ER
visits
• Multiple abd and non-abd pathologies can cause
abd pain, therefore an organized approach is
essential
• Some pathologies require immediate attention
Abdominal pain
3. Introduction
• Abdominal pain is an unpleasant
experience commonly associated with
tissue injury. The sensation of pain
represents an interplay of
pathophysiologic and psychosocial factors.
4. ANATOMIC BASIS OF PAIN
• Sensory neuroreceptors in abdominal organs are located
within the mucosa and muscularis of hollow viscera, on
serosal structures such as the peritoneum, and within
the mesentery.
.
5. • two distinct types of afferent nerve fibers:
myelinated A-delta fibers and
unmyelinated C fibers.
• A-delta fibers are distributed principally to
skin and muscle and mediate the sharp,
sudden, well-localized pain that follows an
acute injury.
6. • C fibers are found in muscle, periosteum,
mesentery, peritoneum, and viscera. Most
nociception from abdominal viscera is
conveyed by this type of fiber and tends to
be dull, burning, poorly localized
7. • The abdominal pain receptors are directly
activated by substances released in
response to:
• local mechanical injury
• Inflammation
• Tissue ischemia and necrosis
• Thermal or radiation injury.
8.
9. Definitions
• Acute abdominal pain with recent onset within
hours-days
• Chronic abdominal pain is intermittent or
continuous abdominal pain or discomfort for
longer than 3 to 6 months.
Abdominal Pain
14. PMH: Similar episodes in past
Other relevant medical problems
Systemic illnesses such as scleroderma, lupus, nephrotic
syndrome, porphyrias, and sickle cell disease often have
abdominal pain as a manifestation of their illness.
PSH: Adhesions, hernias, tumors, trauma
Drugs: ASA, NSAIDS, antisecretory, antibiotics, etc
GYN: LMP, bleeding, discharge
Social: Nicotin, ethanol, drugs, stress
Family: IBD, cancer, ect
Abdominal Pain
History
30. Take Home Points
• Good history and physical exam is important
(History is the most important step of the diagnostic approach )
• Lab studies limitations.
• Imaging studies selection (appropriate for presentation
and location).
• Alarm symptoms oriented investigations
• Early referral of sick patients
• Treatment initiation
Abdominal Pain
31. • Irritable bowel syndrome (IBS)
is an intestinal disorder that
causes abdominal pain or
discomfort, cramping or
bloating, and diarrhea or
constipation. Irritable bowel
syndrome is a long-term but
manageable condition.
What Is IBS
32. • First described in 1771.
• 50% of patients present <35 years old.
• 70% of sufferers are symptom free after 5
years.
• GPs will diagnose one new case per week.
• GPs will see 4-5 patients a week with IBS.
32
Introduction
33. • It is estimated that between 10% and 15% of the
population of North America, or approximately
45 million people, have irritable bowel
syndrome.
• only about 30% of them will consult a doctor
about their symptoms.
• IBS tends to be more common in In women, IBS
is 2 to 3 times more common than in men.
Who Gets IBS?
35. • The positive predictive value (PPV) of the
Manning criteria for the diagnosis of IBS
has ranged between 65 and 75%,
35
36. • At least 12 weeks history, which need not be
consecutive in the last 12 months of
abdominal discomfort or pain that has 2 or
more of the following:
– Relieved by defecation.
– Onset associated with change in stool frequency.
– Onset associated with change in form of the stool.
36
Rome III Diagnostic Criteria.
37. • Supportive symptoms.
– Constipation predominant: one or more
of:
• BM less than 3 times a week.
• Hard or lumpy stools.
• Straining during a bowel movement.
– Diarrhoea predominant: one or more of:
• More than 3 bowel movements per day.
• Loose [mushy] or watery stools.
• Urgency.
37
Rome IlI Diagnostic Criteria.
38. –General:
• Feeling of incomplete evacuation.
• Passing mucus per rectum.
• Abdominal fullness, bloating or
swelling.
38
Rome IlI Diagnostic Criteria.
40. • In people with IBS in hospital OPD.
– 25% have depression.
– 25% have anxiety.
• Patients with IBS symptoms who do not
consult doctors [population surveys]
have identical psychological health to
general population.
• In one study30 % of women IBS sufferers
have fibromyalgia
40
Associated Symptoms
41. IBS Pathophysiology
Heredity; nature vs nurture
Dysmotility, “spasm”
Visceral Hypersensitivity
Altered CNS perception of visceral events
Psychopathology
Infection/Inflammation
Altered Gut Flora
51. Blood test for IBS
• Current best evidence does not support
the routine use of blood tests to exclude
organic gastrointestinal disease in patients
who present with typical IBS symptoms
without alarm symptoms.
52. Reasons to Refer
Age > 45 years at
onset.
Family history of
bowel cancer.
Failure of primary
care management.
Uncertainty of
diagnosis.
Abnormality on
examination or
investigation.
52
55. • Usually very concerned about a serious
cause for their symptoms.
• Take time to explore the patients
agenda.
• Remember that investigations may
heighten anxiety.
55
Patients’ Concerns.
56. • Placebo effect of up to 70% in all
IBS treatments.
• Treatment should depend on
symptom sub-type.
• Often considerable overlap between
sub-groups.
56
Treatment Approaches.
57. • Antispasmodics will help 66%.
• Mebeverine is probably first choice.
• Hyoscine 10mg qid can be added.
57
Pain Predominant.
58. Smooth Muscle Relaxants
• Some patients improve particularly those
whose symptoms are induced by meals
• Most studies that have looked at these
medications have been poorly designed,
poorly controlled, and have not shown
significant benefits above placebo
59. • A data from meta-analysis of 22 studies
involving 1778 patients and 12 different
antispasmodic agents demonstrated
modest improvements in global IBS
symptoms and abdominal pain
• However, up to 68% of patients suffered
side effects when given the high dose
required to improve abdominal pain
Page and Dirnberger, 1981
60. • Poor evidence for efficacy.
• Better evidence for tricyclics and
SSRIs.
60
Antidepressants
61. Tricyclic Antidepressants
TCAs likely modulate pain both centrally and
peripherally
The best data supporting the use of TCAs in the
treatment of IBS is from a large placebo-controlled
study evaluating desipramine .
This highlights the fact that if a patient can tolerate
some of the side effects of a TCA, then he or she is
more likely to note an improvement in chronic
abdominal pain compared with a patient treated with
placebo
[Drossman et al. 2003]
62. Selective Serotonin Reuptake
Inhibitors (SSRIs
• Six studies have been conducted to date,
two each involving fluoxetine, paroxetine
and citalopram
• Talley et al. 2008; Tack et al. 2006; Vahedi et al. 2005; Tabas et al. 2004; Kuiken et al. 2003; Masand et al. 2002].
• Most patients noted an improvement in
overall wellbeing, although none of the
studies showed any benefit with regards to
bowel habits, and abdominal pain was
generally not improved
63. • Only one trial has provided a head-to-head
comparison between a TCA (imipramine
50 mg) and an SSRI (citalopram 40 mg),
• Although neither drug demonstrated
significant improvements in global IBS
symptoms over placebo
• Talley et al. 2008
64. Constipation
Lifestyle Modifications
Bowel Training and Education
Fibre
Twelve randomized controlled trials have been
performed to date evaluating the efficacy of fiber in the
treatment of IBS. Four of these studies noted an
improvement in stool frequency (polycarbophil and
ispaghula husk), while one noted an improvement in
stool evacuation
Toskes et al. 1993; Jalihal and Kurian, 1990; Prior and Whorwell, 1987; Longstreth et al. 1981].
No improvement in abdominal pain
30-50% of patients treated with a fiber product will
have a significant increase in gas
65. Over-the-counter Medications
• PEG
• Lactulose
• Tegaserod stimulate gastrointestinal
peristalsis, increase intestinal fluid
secretion and reduce visceral sensation
• 5 HT agonist FDA approved for chronic
constipation in women.
66. • Lubiprostone stimulates type 2 chloride
channels in epithelial cells of the gastrointestinal
tract thereby causing an efflux of chloride into
the intestinal lumen
• It was approved by the FDA for the treatment of
adult men and women with chronic constipation
in January 2006
• Nausia and diarrhea 6-8%
67. • Increasing dietary fibre is sensible
advice.
• Fibre varies, 55% of patients will get
worse with bran.
• “Medical fibre” adds to placebo effect.
• Loperamide may help
Diarrhea predominant
67
68. Diarrhea
• Loperamide inhibiting intestinal secretion
and peristalsis, loperamide slows intestinal
transit and allows for increased fluid
reabsorption, thus improving symptoms of
diarrhea
69. • Alosetron is 5-HT3 receptor antagonist that
slows colonic transit
• meta-analysis of eight randomized controlled
trials involving 4842 patients determined that
alosetron provided a significant reduction in the
global symptoms of diarrhea, abdominal pain,
and bloating in patients with IBS and diarrhea
• four-fold increased risk for ischemic colitis
compared to placebo
[Ford et al. 2008
71. “Target” Trials
• 1,260 patients with non-constipation irritable
bowel syndrome (IBS) recruited in the US
and Canada
• Rifaximin 550 mg, 3 times daily, for 2 weeks
• Primary endpoint:
– The proportion of subjects who achieved adequate
relief of IBS symptoms for at least 2 weeks during
the first 4 weeks (weeks 3-6) of the 10-week
follow-up phase
• Also assessed relief of IBS bloating and
symptom responses at 12 weeks (10 weeks
after end of therapy)
72. Endpoints Target 1
Rif vs Placebo
Target 2
Rif vs Placebo
Combined
Rif vs Placebo
Adequate
relief of
IBS
symptoms
41% vs 31% 41% vs 32% 41% vs 32%
Adequate
relief of
IBS bloating
40% vs 29% 41% vs 32% 40% vs 30%
All p<0.03
Hitting the Target!
76. Prospective, multicenter, double-blind, placebo-
controlled, crossover trial assessing the efficacy
and safety of the probiotic, VSL#3
Patients treated with VSL#3 had a significant
improvement in the primary endpoint, which was
the global relief of IBS symptoms (p < 0.05).
Secondary endpoints of abdominal pain (p = 0.05)
and bloating (p < 0.001) were also improved.
Guandalini et al. 2008
77. • Avoid caffeine.
• Limit your intake of fatty foods. Fats increase gut
sensations, which can make abdominal pain seem
worse.
• If diarrhea is your main symptom, limit dairy
products, fruit, or the artificial sweetener sorbitol.
• Increasing fiber in your diet may help relieve
constipation.
• Avoiding foods such as beans, cabbage, or
uncooked cauliflower or broccoli can help relieve
bloating or gas.
What about diet?
78. • Hypnosis. Hypnosis can help some people
relax, which may relieve abdominal pain.
• Relaxation or meditation. Relaxation training
and meditation may be helpful in reducing
generalized muscle tension and abdominal pain.
• Biofeedback. Biofeedback training may help
relieve pain from intestinal spasms. It also may
help improve bowel movement control in people
who have severe diarrhea.
Alternative Medicine
